Thrombolysis after initially unsuccessful cardiopulmonary resuscitation in presumed pulmonary embolism
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American Journal of Emergency Medicine
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Thrombolysis after initially unsuccessful cardiopulmonary resuscitation in presumed pulmonary embolism
Abstract
The life-saving administration of thrombolytic therapy after initially unsuccessful cardiopulmonary resuscitation (CPR) in 7 patients with presumed pulmonary embolism (PE) was reported. Seven patients who had cardiac arrest were admitted to our emergency department. The clinical diagnosis of all these patients was highly suspected with PE; therefore, 50 mg recombinant tissue plasminogen activator with 50-mL dilution was administered in a 15-minute period after initially unsuccessful CPR. Of 7 patients, 5 (71.4%) achieved return of spontaneous circulation after CPR and thrombolytic therapy, and 3 (42.9%) of 7 patients were discharged alive through successive treatments. A 90-day follow-up showed that
2 patients were Neurologically intact, and 1 patient was mildly disabled. These results demonstrate that thrombolysis after initially unsuccessful CPR in presumed PE may have beneficial effects.
Pulmonary embolism (PE) has an incidence of approximately 0.1% among the general population and accounts for 2% to 15% of unexpected sudden death, 2% of all cardiac arrest , and 6.5% of noncardiac CA. fulminant PE can cause CA in 41% of cases, with a mortality ranging from 65% to 95% [1].
Fulminant PE can produce CA through multiple mechanisms, most commonly by obstructive shock with severe dysfunction of the right ventricle, and other mechanisms include arrhythmias and vasovagal reflex [2]. Once CA occurs, external chest compression may be effective in fragmenting large emboli and thus re-establishing pulmonary circulation. However, when pulmonary artery is completely obstructed, simple chest compression is difficult to restore spontaneous circulation. Under this circumstance, other measures, such as thrombolysis, emergency thoracotomy, and embolectomy, should be tried. Among these, thrombolysis has attracted much attention because of its easy administration, rapid action, and physiopathologic benefits.
Here, we reported administration of thrombolytic therapy in 7 patients with highly suspected PE after initially unsuccessful cardio- pulmonary resuscitation (CPR) in our emergency department (ED).
These 7 patients with CA were admitted to the ED of Beijing Chaoyang Hospital, which is an university hospital, from February 2013 to December 2013. The initial rhythm of these patients was pulseless electrical activity when arriving at the ED, and the time between occurrence of CA and arrival of ED ranged from 5 to 20 minutes (Table 1). CPR was started immediately according to the recommendations of 2010 CPR guidelines [3].
The initial CPR time ranged from 20 to 45 minutes. During this period, PE was highly suspected based on previous medical histories, symptoms, and laboratory results in these 7 patients (Table 2). Therefore, after obtaining written informed consent
forms from legal relatives, 50 mg recombinant tissue plasminogen activator (Alteplase, Boehringer Ingelheim, Ingelheim am Rhein, Germany) with 50-mL dilution was administered via peripheral intravenous infusion in a 15-minute period during ongoing CPR.
The total CPR time ranged from 28 to 100 minutes. After CPR and thrombolytic therapy, 5 (71.4%) of 7 patients achieved return of spontaneous circulation (ROSC). These patients were admitted into the emergency intensive care unit to receive post-CA therapies. Patient 1 died at 3 days after ROSC because of heart failure. Patient 6 died during the subsequent hospital stay for pulmonary infection. Finally, 3 (42.9%) of 7 patients were discharged alive.
The neurologic outcome was assessed by the Glasgow Outcome Score (GOS) [4]. The 90-day GOS of 3 patients was 5, 5, and 4, respectively, indicating that 2 patients were neurologically intact and 1 patient was moderately disabled (Table 3).
Pulmonary embolism may cause a large number of CA with a high mortality. The high mortality is partly due to the fact that PE is often underestimated [5]. Therefore, clinical suspicion of PE as a cause of CA remains the key in timely treatment. In clinical practice, diagnosis of PE in cases of CA is difficult to establish; under such circumstance, the diagnosis is often a clinical one, mainly based on previous medical histories, symptoms, signs, and auxiliary examinations [6].
In our report, 5 of 7 patients had High-risk factors of PE, and the most suggestive symptoms of PE were dyspnea and syncope. In addition, electrocardiogram showed SIQIIITIII in 2 patients, and echocardiography showed right heart enlargement and pulmonary hypertension in 4 patients. Furthermore, D-dimer levels of these 7 patients were all significantly elevated (Table 2). Taken together, these symptoms and signs should reinforce the clinical suspicion of PE in the presence of CA. On the other hand, 2 patients with ROSC were confirmed to be PE through computed tomography of pulmonary artery and pulmonary radioisotope scanning, whereas another 3 patients with ROSC were highly suspected of PE because of right heart
Table 1
Clinical characteristics of 7 patients
Age (y) |
Sex |
Time between CA and arrival of ED (min) |
Time between start of CPR and thrombolysis (min) |
Total CPR time (min) |
ROSC |
1 56 |
Female |
15 |
35 |
80 |
Yes |
2 40 |
Female |
10 |
25 |
42 |
Yes |
3 48 |
Female |
5 |
20 |
28 |
Yes |
4 22 |
Male |
20 |
20 |
100 |
No |
5 59 |
Female |
20 |
25 |
35 |
Yes |
6 85 |
Male |
10 |
40 |
60 |
Yes |
7 76 |
Male |
5 |
40 |
90 |
No |
0735-6757/(C) 2014
Clinical evidences of PE in 7 patients
High-risk factors of PE |
Symptoms |
D-dimer (mg/L) |
Other manifestations of PE |
Diagnostic evidence of PE |
1 None |
Chest tightness for 1 d |
5.92 |
Right heart enlargement and pulmonary |
Suspected diagnosis: right heart enlargement |
hypertension on echocardiography |
and pulmonary hypertension were improved |
|||
on echocardiography after thrombolysis |
||||
2 None |
Recurrent syncope for 1 mo |
11.85 |
SIQIIITIII on electrocardiogram of other hospital |
Confirmed diagnosis: pulmonary radioisotope scanning showed left PE |
3 8 d after surgery of venous thrombus of Left lower extremity |
Sudden dyspnea for 1 h |
8.96 |
SIQIIITIII on electrocardiogram of other hospital |
Confirmed diagnosis: CT of pulmonary artery showed right PE |
4 Pulmonary cancer |
Dyspnea for 1 mo |
2.75 |
Suspected tumor embolus of pulmonary |
Suspected diagnosis: suspected tumor embolus |
artery on pulmonary enhanced CT of |
of pulmonary artery on pulmonary enhanced CT |
|||
other hospital |
of other hospital |
|||
5 28 d after surgery of |
Dyspnea and chest |
4.62 |
Right heart enlargement and pulmonary |
Suspected diagnosis: right heart enlargement |
lumbar vertebrae |
pain for 7 d |
hypertension on echocardiography |
and pulmonary hypertension were improved |
|
on echocardiography after thrombolysis |
||||
6 Lying on bed for 15 d because |
Dyspnea for 1 d |
3.95 |
Right heart enlargement and pulmonary |
Suspected diagnosis: right heart enlargement |
of fracture of right lower extremity |
hypertension on echocardiography |
and pulmonary hypertension were improved |
||
on echocardiography after thrombolysis |
||||
7 Varicosity of left lower extremity |
Syncope for 1 d |
7.58 |
Right heart enlargement and pulmonary |
Suspected diagnosis: right heart enlargement |
hypertension on echocardiography |
and pulmonary hypertension on echocardiography |
Abbreviation: CT, computed tomography.
enlargement and pulmonary hypertension were significantly im- proved on echocardiography after thrombolysis (Table 2).
The first use of thrombolysis during CPR in a patient with PE was reported by Renkes-Hegendorfer and Hermann in 1974 [7]. Since then, more than 100 cases of successful administration of thrombol- ysis in patients with confirmed or suspected PE during CPR have been published, when the thrombolysis was almost always used as a last resort [8]. Besides case series, clinical studies have also confirmed the effectiveness of thrombolysis [9,10]. However, currently, the use of thrombolysis in CA caused by PE has not been supported by prospective, randomized, controlled trials.
Although thrombolysis is effective in saving patients with PE, many scientific societies have advised against its use during CPR, based on the opinion that ongoing CPR is a contraindication to Thrombolytic treatment due to the risk of causing lethal Bleeding complications. However, Janata et al [11] compared 36 patients who received thrombolysis with 30 patients without thrombolysis with CA due to PE in a retrospective study and concluded that although severe bleeding complications tend to occur more frequently in patients undergoing thrombolysis, the benefit of this treatment might outweigh the risk of bleeding.
In our report, 50 mg recombinant tissue plasminogen activator with 50-mL dilution was administered via peripheral intravenous infusion in a 15-minute period during ongoing CPR. Of 7 patients, 5 (71.4%) achieved ROSC after CPR and thrombolytic therapy, and 3 (42.9%) of 7 patients were discharged alive through successive treatments. A 90-day follow-up found that 2 patients were neurolog- ically intact and 1 patient was moderately disabled. Furthermore, there were no records of major bleeding complications in 5 patients
Prognosis of 5 patients with ROSC
with ROSC. These results demonstrate that thrombolysis is effective and safe in saving patients with CA caused by PE.
In conclusion, outcome of CA depends largely on the existence of potential Reversible causes. Proven or highly suspected thrombotic etiology is an indication for thrombolysis. In this extreme situation, use of thrombolysis should be strongly considered.
Qin Yin, MD Xiao Li, MD Chunsheng Li, MD
Emergency Department of Beijing Chaoyang Hospital Capital Medical University, Beijing, China E-mail address: lcscyyy@163.com
http://dx.doi.org/10.1016/j.ajem.2014.06.031
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Time between ROSC and occurrence of
neurological activities (h)
Time between
ROSC and GCS 12 (h)
90-d GOS
Kurkciyan I, Meron G, Sterz F, Janata K, Domanovits H, Holzer M, et al. Pulmonary embolism as cause of cardiac arrest. Presentation and outcome. Arch Intern Med 2000;160:1529-35.
- 36 No No 1
- 12 24 Yes 4
- 4 24 Yes 5
5 10 24 Yes 5
6 No No No 1
Abbreviation: GCS: Glasgow Coma Score.
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